Recently, I was contacted by a hospital in Ohio about a patient who was transferred to an Aetna Medicare Advantage Plan. It is a point of contention among the hospital and the Medicare Advantage Insurance Companies who handle this plan for hospitals and physician practices. The contention is that most patients on the Medicaid or CHIP have been paying more to Aetna than they are entitled to.
In this case, the patient was a low-income senior who has no insurance and was transferred to an Aetna Medicare Advantage Plan at a relatively low level of care. In other words, the transfer was less than ideal and not a planned transfer at all. This individual was seeking to use Medicaid in the next three months to cover the expense of his stay.
However, the hospital is requesting that the charges be adjusted downward to reflect the change in the patient’s medical needs. The hospital believes that these Medicaid patients are not truly eligible to be covered under Aetna Medicare Advantage Plan because, in their view, they do not meet the low-income definition of being eligible.
Aetna Medicare Advantage Plans tries to make a distinction between a low income senior and one who are well above the low income cutoff. These plans work to accommodate those who do not meet the eligibility requirements but are in desperate need of help.
While Aetna Medicare Advantage Plans does allow Medicare beneficiaries to be part of their plans, they cannot be there for the entire twelve months. These plans are different from HMOs and PPOs because of the additional coverage and flexibility of their plans.
In the case of the nursing home, the nursing home director would not be sending the Medicare Beneficiary to a doctor who had not been certified by the hospital to treat their particular condition. If the Medicare Beneficiary was truly ill, the senior resident would be seen by a doctor who had been properly licensed and trained to care for their condition.
Aetna Medicare Advantage plans available from http://www.comparemedicareadvantageplans.org would never have taken over these services as long as the hospital is concerned. The hospitals are concerned that they be paid for the services rendered because the money that the insurance companies pay to the hospitals is so small compared to what the hospital actually receives from Medicare.
In these circumstances, the Medicare Advantage Company is taking on extra responsibility because it is the point of contact for the Medicare Beneficiary. In some cases, they even take the place of the hospital in some situations, like if the hospital cannot be reached or someone at the hospital refuses to answer the phone when a Medicare Beneficiary calls them.
The best way to resolve this matter is to communicate with the hospital and let them know how you feel about your Medicaid or CHIP Benefits being charged more than you are entitled to. If you feel you are the subject of a billing problem, ask for a copy of the documentation they are using to justify the difference.
You may find that there is nothing in the billing and should not be. In other situations, you may be able to convince the hospital to help you receive a better bill.
Often times, Medicare or other health insurance will lower the charges for the services so as to continue doing business with the hospital. The amount of money that you pay to Aetna Medicare Advantage Plans depends on the details of your plan and the experience of the hospital.
If the billing discrepancy is an issue, contact your local representative of Aetna Medicare Advantage Plans. This process should be easy to resolve.